State Moves To Give Nurses Independence From Doctors

HARTFORD – The House of Representatives on Monday approved a bill giving some nurse practitioners greater independence to diagnose and treat patients without doctors' direction, a policy shift that is likely to lead to profound changes in the way health care is delivered in the state.

Gov. Dannel P. Malloy proposed the measure and intends to sign it into law.

"With the healthcare industry growing and changing, the role of advanced practice registered nurses remains critical,'' Malloy said in a statement minutes after the bill passed 110 to 35. "This bill increases access to primary care across Connecticut by allowing advanced practice registered nurses to do more of what they do so well – evaluating, screening, physical examinations and management of many routine medical conditions such as hypertension, diabetes and asthma."

The proposal, which was endorsed by the Senate earlier this month, will allow advanced practice registered nurses, or APRNs, to diagnose patients and prescribe drugs, among other duties. APRNs would have to work in collaboration with a physician for their first three years, but after that, they would be free to practice on their own.

Supporters say APRNs are already key players in the delivery of health care and perform a wide variety of medical tasks, though under the current rules they can only do so under the direction of a doctor. Their role is expected to grow even more important because of the Affordable Care Act, which has added millions of people to the ranks of the insured and driven a growing need for more primary care providers.

Seventeen states and the District of Columbia allow nurse practitioners to work independently, without a physician's oversight, according to an article published in July by Stateline. Similar measures are pending in several other states.

"APRNs are a valued and integral part in the health care system,'' said Rep. Peggy Sayers, D-Windsor Locks. "These independent licensed providers are an answer to the primary health care shortage facing Connecticut."

But critics, including some physicians' groups, cite concerns about the gap in training between APRNs, who hold graduate degrees earned after two or three years in a master's program, and family physicians, who generally complete four years of medical school and three years of residency.

"The training of an RN is very different from the training that a doctor has in the medical school,'' said Rep. Prasad Srinivasan, R-Glastonbury.

Srinivasan, a physician, noted that the health care system is changing rapidly. He conjured the image of a Norman Rockwell illustration, depicting an authoritative-looking family doctor talking down to the mother of his young patient.

"We are aware of the changing landscape in medicine,'' Srinivasan said, "a paradigm shift from a single person calling all the shots ... to a team effort comprising of the MD, the APRN, the PA [physician's assistant].

"Is the present collaborative agreement perfect? The answer is no,'' Srinivasan added. "But two wrongs do not make it right, and that is my concern."

The Connecticut State Medical Society expressed its disappointment with the bill.

"It is fundamentally an issue of patient safety and health care transparency," said Dr. Michael Saffir, the group's president. "Studies have shown that the team-based model, where physicians and APRNs collaborated to provide coordinated patient care, is the most effective approach to quality patient care. This bill moves in the opposite direction, by removing collaboration and fragmenting the care team."